Use of Opioids in Patients with Cancer in North Carolina · 08-04-2020 · Mindfulness Based...

UNC Cancer Network Presented on 4/8/2020

For Educational Use Only 1

Use of Opioids in Patients with Cancer in North Carolina

Amy Goetzinger, PhD

Pain Psychologist, Division of Pain MedicineAssociate Professor, UNC School of Medicine

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Disclosures• None

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Learning Objectives1. Explain factors and the current response of

the opioid crisis over time

2. Identify best practices of opioid use for cancer-related pain

3. Describe alternative strategies and therapies for cancer-related pain

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Learning Objectives1. Explain factors and the current response of

the opioid crisis over time

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Prevalence of Chronic Pain in the US

CDC, 2016

-20% of the US population (50 million) with chronic pain-8% with high impact pain-Pain increases with age

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Chronic Pain & The Opioid Crisis

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Overdose Concerns

Pain as a vital sign

Opioids prescribed widely

in the USHeavy Marketing

of Opioids

Chronic PainCancer

Pain

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Chronic Pain & The Opioid Crisis

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Overdose Concerns

Pain as a vital sign

Opioids prescribed widely

in the USHeavy Marketing

of Opioids

Chronic Pain

Cancer Pain

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Prevalence of Cancer-related Pain

• 39% after curative treatment• 55% during treatment• 66.4% in advanced, metastatic, or terminal disease• Overall, 30% with moderate to severe pain

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Concern about opioids?• Risk of overdose• Risk of abuse/misuse

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CDC develops new guidelinesMarch 2016, revised

• CDC developed and published the CDC Guideline for Prescribing Opioids for Chronic Pain to provide recommendations for the prescribing of opioid pain medication for patients 18 and older in primary care settings. Recommendations focus on the use of opioids in treating chronic pain (pain lasting longer than 3 months or past the time of normal tissue healing) outside of active cancer treatment, palliative care, and end-of-life care.

• MMWR: CDC Guideline for Prescribing Opioids for Chronic Pain• Factsheet: Calculating Total Daily Dose of Opioids for Safer Dosage• Mobile App: CDC Opioid Guideline

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https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1er.htm

https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm%3FCDC_AA_refVal=https%253A%252F%252Fwww.cdc.gov%252Fmmwr%252Fvolumes%252F65%252Frr%252Frr6501e1er.htm

https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf

https://www.cdc.gov/drugoverdose/prescribing/app.html



CDC Guideline Overview• The CDC Guideline addresses patient-centered clinical practices including conducting thorough

assessments, considering all possible treatments, closely monitoring risks, and safely discontinuing opioids. The three main focus areas in the Guideline include:

• Determining when to initiate or continue opioids for chronic pain » Selection of non-pharmacologic therapy, nonopioid pharmacologic therapy, opioid therapy» Establishment of treatment goals» Discussion of risks and benefits of therapy with patients

• Opioid selection, dosage, duration, follow-up, and discontinuation» Selection of immediate-release or extended-release and long-acting opioids» Dosage considerations» Duration of treatment» Considerations for follow-up and discontinuation of opioid therapy

• Assessing risk and addressing harms of opioid use» Evaluation of risk factors for opioid-related harms and ways to mitigate patient risk» Review of prescription drug monitoring program (PDMP) data» Use of urine drug testing» Considerations for co-prescribing benzodiazepines» Arrangement of treatment for opioid use disorder

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What happened next?

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Revising Perspectives around Opioids

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Opioids in the Cancer Setting

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Effects on Patients & Providers

Patients• Fear

» Poor pain control» Abuse potential

• Access

Providers• Screening• Assessment• Monitoring• Documentation

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Management of Chronic Cancer Pain

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Learning Objectives

2. Identify best practices of opioid use for cancer-related pain

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Opioid Screening & Mitigating Risk

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Selection and Risk

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Screening and Monitoring

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Pain Contract / Pain Treatment Agreement• Bring all opiate medications with

original prescription bottle to each clinic visit

• Will not abuse alcohol or use illicit drugs

• Agree to urine, blood or other drug screenings

• Provider may perform criminal background check and track pharmacy prescriptions

• Refill not provided if lost or stolen (police report)

• Medication not continued if lost or stolen >1x

• If arrested or incarcerated related to legal or illegal substances, medication refills will be denied

• Refills require clinic visit• Follow recommendations regarding

multimodal pain management strategies (AT, PT, exercise prescriptions, pain psychology, MH follow up)

¢ Provider name¢ Patient name¢ Patient signature¢ Date (updated yearly)¢ 1 pharmacy¢ 1 prescribing physician/clinic

� For exception, approval beforehand� Following emergent hospitalization,

alert within 48 hours of discharge¢ Update all medications including

opiates with other providers¢ Keep all appointments, no-show

policy¢ Take all medications exactly as

prescribed¢ Self escalations not permitted¢ No early refills

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Part 3 – Identifying at Risk Behavioral Aberrant behaviors

Most Common• Preference for short acting

medication• Running out of medications

early/unsanctioned dose escalations

• Obtaining pain medication from other physicians

• Borrowing pain medication from others

More Severe• Obtaining prescription drugs

from nonmedical sources (i.e. on the street)

• Concomitant abuse of related illicit drugs (marijuana or other)

• Recurrent prescription losses• Injecting or inhaling oral

formulation• Prescription forgery

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• Risk-taking or thrill seeking behavior

• Heavy tobacco use• History of psychopathology

including severe depression, suicidality, bipolar I disorder, severe anxiety, psychotic disorders, somatization, personality disorder

• Psychosocial stressors• Family history of substance abuse• Poor social support

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Opioid Screening Tools

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1. Opioid Risk Tool (ORT)

2. Screener and Opioid Assessment for Patients in Pain-Revised (SOAPP-R)

3. Current Opioid Misuse Measure (COMM)

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Current Opioid Misuse Measure

Scoring:< 9 low adherence risk≥ 9 elevated adherence risk

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Helpful Online Resources for Psychometrics

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Opioid Dependence – Opioid Use Disorder (OUD)

• F11.10 - Mild: 2–3 symptoms• F11.20 - Moderate: 4–5

symptoms• F11.20 - Severe: 6 or more

symptoms

Specifiers» Early Remission: no criteria for 3-12

months#» Sustained Remission: no criteria for 12+

months#

1. Using more & for longer2. Difficulty controlling/cutting

down3. Obtaining & using4. Craving5. Problems at work, school,

home6. Problems with people7. Less time with functional

/pleasurable activities8. Continued in dangerous

situations9. Continued use despite MH

and/or health problems10. Tolerance11. Withdrawal

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Opioid Contract & Behavioral Adherence Plan

Standard Opioid Agreement

Vs.

Extra behavioral goals that are considered mandatory-mitigating risk

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Case Example 1• Tanya

» 56 yo AA female with breast cancer• s/p mastectomy and currently undergoing

chemotherapy• Pmhx + for type 2 DM

» Possible sources of pain• From cancer • Post surgical pain – post acute vs. chronic

(nerve damage)• Chemotherapy• DM neuropathic pain

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Case Example 2• Charles

» 75 yo C male with h/o oropharyngeal cancer• s/p surgery and radiation therapy• 6 years in remission

» Possible sources of pain• From surgery• From radiation

» Other symptoms or concerns?

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Case Example 3• Dennis

» 35 yo C male with metastatic breast cancer• diagnosed years after pain started (stage III)• palliative radiation therapy for metastases to his

skull, spine, and mediastinum• chemotherapy x 7 years• Hospice care x 2 with PCA and port • Fentanyl 150 mcg/hr and dilaudid 4mg q4 hr

prn

» Diversion potential• Port

» Intrathecal pump?3/4/20 33

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Opioid Dosing

www.cdc.gov

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Opioid Dose Calculator

http://www.agencymeddirectors.wa.gov/Calculator/DoseCalculator.htm

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Hypothetical case example:Oxycodone 5mg q6 hr, up to 4x/day = 30 mme

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Case example 3 (metastatic/palliative):Fentanyl 150 mcg/hr + dilaudid 4mg 4x/day = 520 mme

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Dosing Guidelines

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CDC Resources

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Learning Objectives

3. Describe alternative strategies and therapies for cancer-related pain

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The Evolution of Behavioral Therapies

1st waveClassical conditioning and operant learning

3rd waveAddresses metacognition, acceptance, mindfulness, dialectics, spirituality, and personal values

Acceptance and Commitment Therapy (ACT) and Mindfulness Based Stress Reduction (MBSR)

2nd waveCognitive Therapy and Cognitive Behavioral Therapy (CBT)

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Empirically Validated Therapies(for chronic pain, depression, anxiety disorders)

Main Approaches1. Cognitive Behavioral Therapy (CBT)2. Acceptance and Commitment Therapy (ACT) 3. Mindfulness Based Strategies

Also Helpful• Dialectical Behavior Therapy – for BPD and stress reactivity• Behavioral sleep hygiene, CBTi – for sleep• Trauma – CPT, EMDR, Prolonged Exposure• MAT + behavioral therapies above – OUD and SA

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Search: Ebt for Adolescents and Adults with Mult Subtance Abuse Concerns

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National Resources and Programs

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NC Methadone Maintenance Treatment Centers and Buprenorphine Treatment Providers (via SAMSHA)

http://www.samhsa.gov/medication-assisted-treatment/physician-program-data/treatment-physician-locator

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NC Drug Addiction Resources

• http://www.nchrc.org/• Free naloxone

overdose/rescue kits

• Since the Overdose Prevention Project (OPP) started in Aug 2013 NCHRC has dispensed over 101,000 free overdose rescue kits, and 13,394 confirmed reports of life saving use of naloxone (data as of 1/20/2019)

• NCHRC engages in grassroots advocacy, resource development, coalition building and direct services for people impacted by drug use, sex work, overdose, immigration status, gender, STIs, HIV and hepatitis

• NCHRC also provides resources and support to the law enforcement, public health and provider communities

• North Carolina Harm Reduction Coalition (NCHRC)

• Main Office: Raleigh• Secondary Office:

Wilmington

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http://www.nchrc.org/



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Alcohol/Drug Counsel of North Carolina

www.alcoholdrughelp.org

1-800-688-4232» 24/7 Help Available» Confidential Information and

referral» Referral specialists available Mon-

Sat 8am-6pm» Live crisis services available All

Nights and Sunday

Levels of Care1. Outpatient services

<9 hrs/week2. Intensive outpatient treatment

9+ hrs/week3. Partial hospitalization

psychiatric, medical & lab services4. Clinically managed low intensity residential

Eg, halfway house (5 hrs of addiction services)

5. Clinically managed medium intensity residential therapeutic rehabilitation facility (to address more severe medical, emotional, cognitive, and behavioral problems)

6. Clinically managed high-intensity residentialSubstance Abuse Non-Medical Community

Residential Treatment (24 hr recovery env)

7. Medically monitored intensive inpatient surfaceSubstance abuse medically monitored community residential treatment

8. Medically managed intensive inpatient servicesAcute care general hospital, psychiatric hospital, psychiatric unit in an acute care hospitalNational Suicide Prevention Lifeline

1-800-273-8255

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Mental Health & Substance Abuse Referrals

• Medicaid» LMEs» MCOs

• Medicare» www.medicare.gov» Find doctors

• Psychologist• Psychiatrist• Mental health

counselor

• Private Insurance» Direct through

insurance website or referral number

» Psychology Today Database

» Find a therapist, psychiatrist, treatment facility

» www.psychologytoday.com

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http://www.medicare.gov/



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Referrals for Mental/Behavioral Health and Substance Abuse Treatment in North Carolina

**MEDICAID AND SELF PAY OPTIONS**LME / MCOThese LME/MCO contacts connectpatients with MH/Substance Abuse treatment facilities within their counties/region.

All Medicaid and uninsured patients must go through this route. These are also options for individuals with other insurance types.

Based on NC CountyCardinal Innovations Healthcare Solutions OfficePhone: 704-939-7700Crisis Line: 800-939-5911Counties Served: Alamance, Cabarrus, Caswell, Chatham, Davidson, Davie, Forsyth, Franklin, Granville, Halifax, Mecklenburg, Orange, Rockingham, Person, Rowan, Stanly, Stokes, Union, Vance and Warren

Alliance Behavioral Healthcare OfficePhone: 919-651-8401Crisis Line: 800-510-9132Counties Served: Cumberland, Durham, Johnston, Wake

https://www.ncdhhs.gov/providers/lme-mco-directory

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Referrals for Pain Psychology at UNC• Ambulatory Referral to Pain

Psychology

» Order for full evaluation with pain psychologist - Outpatient

• Amy Goetzinger, PhD• Seema Patidar, PhD• Skye Margolies, PhD

» Coverage at UNC Southern Village Pain Clinic and Hillsborough outpatient

» Pain Psychiatrist – Dr. Rebecca Bottom

• Inpatient Medical Center Referrals

» To chronic pain service• Dr. Patidar available for

behavioral health assessment and treatment Wednesday mornings only

• Dr. Goetzinger available for OUD behavioral health assessment and treatment at UNC Hillsborough hospital on Friday mornings beginning Jan 2020

UNC Pain ManagementPhone: 984-974-6688Fax: 984-974-6793

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[email protected]

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Use of Opioids in Patients with Cancer in North Carolina · 08-04-2020 · Mindfulness Based...

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